Provider Demographics
NPI:1063102937
Name:TARDENCILLA GUTIERREZ, ALEJANDRO ANTONIO
Entity type:Individual
Prefix:
First Name:ALEJANDRO ANTONIO
Middle Name:
Last Name:TARDENCILLA GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 LAKOTA DR APT 203
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5395
Mailing Address - Country:US
Mailing Address - Phone:407-923-8493
Mailing Address - Fax:
Practice Address - Street 1:7040 LAKOTA DR APT 203
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5395
Practice Address - Country:US
Practice Address - Phone:407-923-8493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23-164246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant